Características de los microaspersores.

Unless specifically stated otherwise in the Group Policy or elsewhere in this Certificate, or in the Schedule of Coverage, or any Rider or Endorsement that may be attached to the Group Policy, no payment will be made under any benefit of the Group Policy for Expenses Incurred in connection with the following: 1) Charges in excess of the Maximum Allowable Charge.

2) Charges for non-Emergency Care in an Emergency Care setting to the extent that they exceed the charge that would have been incurred for the same treatment in a non-Emergency Care setting. 3) Weekend admission charges for non-Emergency Care Hospital services. This exclusion applies only

to such admission charges for Friday through Sunday, inclusive.

4) Confinement, treatment, services or supplies not Medically Necessary. This exclusion does not apply to preventive or other health care services specifically covered under the Group Policy.

5) Services, other than Emergency Services, received outside the United States whether or not the services are available in the United States.

6) Injury or Sickness for which benefits are payable under any state or federal workers' compensation, employer's liability, occupational disease or similar law.

7) Injury or Sickness for which the law requires the Covered Person to maintain alternative insurance, bonding, or third party coverage.

8) Injury or Sickness arising out of or in the course of past or current work for pay, profit, or gain, unless workers' compensation or benefits under similar law are not required or available.

9) Services for military service related conditions regardless of service in any country or international organization.

10) Treatment, services, or supplies provided by the Covered Person; his or her spouse; a child, sibling, or parent of the Covered Person or of the Covered Person's spouse; or a person who resides in the Covered Person's home.

11) Confinement, treatment, services or supplies received where care is provided at government expense. This exclusion does not apply if: a) there is a legal obligation for the Covered Person to pay for such treatment or service in the absence of coverage; or b) payment is required by law.

12) Dental care including dental x-rays; dental appliances; orthodontia; and dental services resulting from medical treatment, including surgery on the jawbone, and radiation treatment.

13) Cosmetic services, plastic surgery or other services that:

a) are indicated primarily to change the Covered Person's appearance; and b) will not result in significant improvement in physical function.

This exclusion does not apply to:

a) treatment to correct a significant disfigurement caused by medically necessary surgery or by an injury;

b) service that is rendered to a Dependent child due to congenital disease or anomaly; or

c) Reconstructive breast surgery following a mastectomy; or are necessary for treatment of a form of congenital hemangioma.

14) Non-prescription drugs or medicines; vitamins, nutrients and food supplements, even if prescribed or administered by a Physician unless otherwise required by law.

15) Any treatment, procedure, drug or equipment, or device which KPIC determines to be experimental or investigational. This exclusion does not apply to Services covered under Clinical Trials in the GENERAL BENEFITS section and to experimental or investigational drugs that are used to treat cancer if one or more of the following conditions is met:

a) The drug is recognized for treatment of the Covered Person’s particular type of cancer in the United States Pharmacopoeia Drug Information, The American Medical Association Drug Evaluations or The American Hospital Formulary Service Drug Information publication; or b) The drug is recommended for treatment of the Covered Person’s particular type of cancer

and has been found to be safe and effective in formal clinical studies, the results of which have been published in either the United States or Great Britain.

c) Coverage for Routine Patient Care Costs incurred in connection with the provision of goods, services, and benefits to such dependent children in connection with approved clinical trial programs for the treatment of children’s cancer with respect to those dependent children who:

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ii) Are enrolled in an approved clinical trial program for treatment of children’s cancer; and iii) Are not otherwise eligible for benefits, payments, or reimbursements from any other third

party payors or other similar sources.

16) Special education and related counseling or therapy; or care for learning deficiencies or behavioral problems, except as otherwise provided for the treatment of Autism Spectrum Disorder. This applies whether or not the services are associated with manifest Mental Illness or other disturbances.

17) Services, supplies or drugs rendered for the treatment of obesity or weight management; however, Covered Charges made to diagnose the causes of obesity or charges made for treatment of diseases causing obesity or resulting from obesity are covered.

18) Confinement, treatment, services or supplies that are required: a) by a court of law; or b) for insurance, travel, employment, school, camp, government licensing, or similar purposes.

19) Personal comfort items such as telephone, radio, television, or grooming services.

20) Custodial care. Custodial care is: a) assistance with activities of daily living which include, but are not limited to, activities such as walking, getting in and out of bed, bathing, dressing, feeding, toileting and taking drugs; or b) care that can be performed safely and effectively by persons who, in order to provide the care, do not require licensure or certification or the presence of a supervising licensed nurse.

21) Care in an intermediate care facility. This is a level of care for which a Physician determines the facilities and services of a Hospital or a Skilled Nursing Facility are not Medically Necessary.

22) Routine foot care such as trimming of corns and calluses.

23) Confinement or treatment that is not completed in accordance with the attending Physician's orders. 24) Services of a private duty nurse.

25) Medical social services except those services related to discharge planning in connection with: a) a covered Hospital Confinement; b) covered Home Health Care Services; or c) covered Hospice Care. 26) Living expenses or transportation, except as provided under Covered Services.

27) Reversal of sterilization.

28) Services provided in the home other than Covered Services provided through a Home Health Agency. 29) Maintenance therapy for rehabilitation.

30) The following Home Health Care Services: a) meals,

b) personal comfort items, c) housekeeping services.

31) Biotechnology drugs and diagnostic agents. The following biotechnology drugs are excepted from this exclusion: Human insulin, vaccines, biotechnology drugs administered for the treatment or diagnosis of cancer, and Dornase for the treatment of cystic fibrosis, human growth hormones prescribed or administered for the treatment of documented human growth hormone deficiency such as Turner's Syndrome.

32) Covered Services received in connection with a surrogacy arrangement in which a woman agrees to become pregnant and to surrender the child to another person or persons who intend to raise the child.

33) Any drug, procedure or treatment for sexual dysfunction regardless of cause, including but not limited to Inhibited Sexual Desire, Female Sexual Arousal Disorder, Female Orgasmic Disorder, Vaginismus, Male Arousal Disorder, Erectile Dysfunction and Premature Ejaculation.

34) Chiropractic Services other than manual manipulation of the spine to correct subluxation demonstrable by x-ray.

35) Acupuncture; massage therapy; or hypnotherapy.

36) Health education, including but not limited to stress reduction; ; or c)

37) Hearing therapy, or hearing aids. This exclusion includes hearing exams to determine appropriate hearing aid, as well as hearing aids or tests to determine their efficacy.

38) Radial keratotomy or any other surgical procedure to treat a refractive error of the eye. 39) Vision hardware, including glasses, contact lenses or the fitting of glasses or contact lenses. 40) Services for which no charge is normally made in the absence of insurance.

41) Artificial insemination and advanced reproductive techniques such as IVF, ZIFT and GIFT for the treatment for infertility.

42) Services provided by a Home Health Aide.

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GENERAL LIMITATIONS AND EXCLUSIONS

44) Computed Tomographic Colonography screening except when endoscopic colonoscopy cannot be safely performed, such as in anatomical blockage of the colon.

45) Any Services described in this Treatment of Autism Spectrum Disorder that are not specifically required to be provided or arranged by Kaiser Permanente Insurance Company pursuant to an individualized family service plan, an individualized education plan as required by the federal Individuals with Disabilities Education Act, or an individualized service plan.

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